How to tackle HIV stigma among health care workers

Stemming in part
from negative associations with the virus itself, and in part from marginalisation
of populations highly impacted by the virus, stigma and discrimination has
long dissuaded people from accessing HIV-related services. Studies presented last week at the Nineteenth International AIDS Conference showed that health care
workers also hold negative associations of people living with HIV, but that
basic education can help to combat misinformation and discrimination.

Presenting on a
panel entitled “Bad
Manners at the Bedside: Stigma and Discrimination in Health Care Settings,”
Maria Ekstrand of the University of California, San Francisco said that
"stigma in health care settings is much more than a theoretical
construct…it affects health outcomes."

With colleagues in India, Ekstrand
considered misconceptions, stigma, and discrimination amongst nurses in Mumbai
and Bangalore. A whopping 70% of 393 respondents interviewed said "people
who get HIV typically get what they deserve because they've been engaging in
behaviors that they shouldn't have."

Two-thirds of groups displayed
prejudicial attitudes against marginalised groups at high-risk of HIV
infection, and "the vast majority of the participants…think that mandatory
testing and other coercive policies aimed at people with HIV should be
implemented.”

Nearly half of
respondents cited fears over being infected at work, "possibly due to lack
of universal precautions," said Ekstrand. While the majority understood
basic information about HIV transmission, 26% thought that HIV could be
transmitted from sharing a glass; 28% thought they could get infected by using
a toilet that an HIV-positive person had used. "Many were hesitant [about]
drawing blood or would take extra precautions," such as wearing two pairs
of gloves.

Dr. Li Li of the
Chinese Centers for Disease Control and Prevention and the University of Los
Angeles found similar results in a study in Yunnan and Fujian provinces in
China. Li said that while there were "social, cultural, structural, and
individual factors," fear of contracting HIV from their positive patients
presented a significant barrier to care. This was due in part due to poorly
implemented universal precaution measures.

"Some…providers have never
heard of universal precaution, and some of them try to avoid patients they
think are HIV positive for their own protection," explained Li. The White
Coat Warm Heart randomised control trial reinforced universal precaution both
to reduce stigma and discrimination, and to ensure occupational safety.

Li noted that
the difference in HIV prevalence in Yunnan and Fujian provinces was associated
with differing levels of knowledge and differing attitudes. Considering
baseline surveys, health care workers in Yunnan, with a higher HIV prevalence
rate, displayed higher HIV knowledge; higher perceived institutional support;
and lower avoidance than their counterparts in Fujian, with a relatively lower
prevalence rate. Yet this was also matched with higher perceived risk.

"We
certainly need to consider regional differences in study design," said Li.
"A one model fit all will not work…There will not be magic bullets for HIV
stigma reduction."

But by providing
"engaging and interactive" intervention activities to nearly 880
service providers - with another 880 in a control arm - and to 456 popular
opinion leaders in 20 hospitals "we observed significant improvement in
reducing general stigma attitude; reducing avoiding intent; and increasing
perceived institutional support in the intervention arm,” said Li.

These
positive results were found in both provinces. “We are very excited about these
outcomes. Our biggest challenge now is to how to put research results into
routine medical practice."

Presenting on
her doctoral research, Oralia Gómez-Ramírez of
the University of British Columbia noted that local political, social, and
cultural conditions need to be taken into account when creating health care
services, especially for marginalized populations. Her anthropological work
focuses on a trans-gendered health unit nestled within the HIV clinic in Mexico
City, the creation of which sparked intense controversy among the city's trans
community.

While "all activists consider a trans-health program a success,
they differed in opinions on its impacts," said Gómez-Ramírez. While some trans-women interviewed were happy with
the service, and used it, others were "profoundly dissatisfied"
because of the perceived "automatic association with trans-health and
HIV/AIDS,” explained Gómez-Ramírez.

"Many trans women, and particularly sex workers, chose not to access
HIV-related and other trans services available to them in the HIV clinic;” some
even "forcefully advocated for the removal of the trans-health programme
from the HIV clinic," she said.

Interviewees who
participated in sex work were especially reluctant, as they worried that
obtaining services from an HIV clinic would harm them economically. They
"could not afford the suspicion of being found to be HIV positive,"
said Gómez-Ramírez, as "this
would jeopardize their already precarious position in the informal economy of
street-based sex work."

These results
highlight persistent HIV-related stigma across myriad sectors of society, and
double stigma faced by marginalized communities disproportionately affected by
HIV. "HIV stigma and discrimination exists at the local level," said Gómez-Ramírez. "The HIV clinic still carries
stigma."

Manal Benkirane
of the US Naval Medical Research Unit in Cairo presented the findings of a
study that attempted to determine whether a doctor's gender was predictive of
HIV-related stigma and/or discriminatory practices. She found that females
"gave more wrong answers" - such as believing that mosquitoes can
transmit HIV - and were more likely to refuse treatment to patients. Both males
and females were more willing to treat HIV positive children than intravenous
drug users or sex workers living with the virus; regardless of gender, doctors
aged 35-44 were less likely to discriminate than both their older and younger
counterparts.

Benkirane said
that the findings relate to gender differences in Egyptian society as a whole,
noting that women may display stronger discriminatory practices because of fear
of contracting HIV, as “females would be more stigmatized than males in
Egyptian society.” Additionally, given cultural norms, "female decisions
[are] more influenced by their family ties and tradition" and "would
have less access to information."

But perceptions
among health care workers are
changing, especially in high-burden settings facing a generalised epidemic. In
Uganda—which hosts a national prevalence rate of 7.4%—community members interviewed
as part of a qualitative study to understand, and mitigate, HIV stigma in
health care settings said that "health workers have now a positive
attitude towards them," according to Lydia Mugo of Bon Sante Consulting.
"One said that he had never seen any discrimination at all."

However, HIV-positive health care workers interviewed said that they faced discrimination by
fellow health care workers: respondents reported being sidelined from training
activities; given extra work; and being told to treat HIV positive patients
"because they had HIV themselves.”

One interviewee said that other staff
"mark" objects used by an HIV positive health care worker, such as
utensils in communal kitchens, so that those without the virus would not use
it.

Mugo said that
self-testing among respondents "was a wide-spread activity," as
health care workers "were afraid that if they were to go to someone and
they were positive, it would become wide-spread knowledge." HIV positive
health workers preferred to go to another facility to receive treatment, where
they would be treated as just another patient.

Mugo said that
outreach and care programs tailored specifically to health care workers were
needed. One interviewee told her, "the biggest problem that the health
workers have is that the general public assume health workers know
everything…so nobody intervenes."

Sara Belton of
the London School of Economics and Political Science presented qualitative
research which suggested that the roll-out of anti-retrovirals helped to combat
stigma and discrimination amongst health care workers in Kabarole district,
Uganda because the drugs "transformed HIV from being a death sentence to
being a manageable disease."

Health care
workers interviewed "reported an improved sense of professionalism from
using the ARVs in their clinical practice," said Belton. "But also
from the interpersonal side of things, [ARVs] help health care workers because
of the positive impact they see on their patients." Because of visible
improvements in patients that they treat, "ARVs…help health care workers
to cope with the difficult work that they do."

Belton visited the Kabarole district in 2009, and then
again in 2011, noting a "huge difference that ARVs had made" in the
period between the two visits. "In 2009…they were in the middle of
roll-out, there was still a lot of shortages, there were still a lot of
logistical problems…In 2011 they had a much more secure and stable source of
the drugs, which happened just before I was there. I'm not sure if I captured
the euphoria…or if this is something that could be longer lasting."

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.

The Community Consensus Statement is a joint initiative of AVAC, EATG, MSMGF, GNP+, HIV i-Base, the International HIV/AIDS Alliance, ITPC and NAM/aidsmap

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NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member
of your healthcare team for advice tailored to your situation.